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168
6.5 Fenestration of Hepatic Cysts
Operative Technique
T2
T3
Fig. 6.5.3 Fenestration of hepatic cysts. Aspirating the cyst.
Aspirate with a 5-mm instrument. Remove as much of the fluid as
possible. If the aspirate is discolored with bile, carefully inspect the inner
cyst wall for bile leakage after resecting the cyst. Decompressing the cyst
causes the wall to collapse and allows one to demonstrate the border between the cyst and the hepatic parenchyma. This is the plane of resection
(see Fig. 6.5.2 for key to instrument numbers).
T3
Fig. 6.5.4 Fenestration of hepatic cysts. Partial resection of the cyst.
Now gradually incise the cyst wall directly where it joins the hepatic
parenchyma using electrocautery (hooked electrode or scissors) or ultrasonic dissection. Carefully inspect the resection site for bleeding or bile
leakage. Coagulate the tissue. In the presence of persistent bleeding or
bile leakage, place sutures laparoscopically. If one is using an ultrasonic instrument, expose large vascular structures and ligate them with clips.
After the surgeon has resected the cyst wall, it should be removed
through an instrument trocar, or placed in a sterile bag and extracted
through the incision. Large cyst walls may be removed through an extractor trocar. Send the material to the laboratory for histologic studies;
wherever possible, obtain a frozen section to verify or exclude a tumor.
Examine the surface of the inner cyst wall. Take a biopsy if pathological
changes are detected. The surgeon can control bile leakage by clipping or
suturing the bile duct where it can be seen and exposed directly. Observe
the clip or suture to verify closure. If this is not possible or there is doubt, a
Roux-en-Y cystojejunostomy or jejunal loop with an end-to-side anastomosis is indicated. If a jejunal drainage procedure is not necessary, then
push a fold of the omentum into the interior of the cyst with a swab. Fix it
to the interior of the cyst or the resected edge with metal clips. Introduce
a drain through one of the trocar incisions and place it in the cyst (see
Fig. 6.5.2 for key to instrument numbers).
Bibliography
Lai ECS, Wong J. Symptomatic nonparasitic cysts of the liver. Wld. J. Surg.
1990; 14:452.
Lange V, Meyer G, Rau H, Schildberg FW. Minimal-invasive Eingriffe b ei soli-
tären Lebercysten. Chirurg 1992; 63:349.
Litwin DEM, Taylor BR, Greig P, Langer B. Nonparasitic cysts of the liver. Ann.
Surg. 1987; 45.
Moritz E. Laparoskopische Fenestrierung von solitären Riesencysten der
Leber. Chirurg 1992; 63:379.
Reck T, Köckerling F, Gastinger I, Schneider I, Schneider B, Bin Dayna K, Gall
FP. Laparoskopische Resektion nicht-parasitärer Leberzysten. MIC 1993;
2:14.
Sanchez H, Gagner M, Rossi RL, Jenkins RL, Lewis WD, Munson JL, Braasch
JW. Surgical management of nonparasitic cystic liver disease. Amer. J.
Surg. 1991; 113.
Schubert Th, Treutner K-H, Winkeltau G, Treumann T. Die nichtparasitäre Le-
berzyste. Akt. Chir. 1989; 24:12.
Z’graggen K, Metzger A, Klaiber C. Symptomatic simple cysts of the liver:
treatment by laparoscopic surgery. Surg. Endosc. 1991; 5:224.
169
7. Intra-abdominal and Endoluminal Gastric Operations
7.1 Closure of Peptic Ulcer Perforation
A. Pier , F . Götz
Goals and Methods
A patient presenting with perforation of a gastroduodenal ulcer
must be prepared for urgent operation while undergoing simul-
taneous resuscitation and preoperative diagnostic studies.
The objective of surgical intervention is:
− Laparoscopic localization of the perforation site.
− Excision of the edges of the ulcer and repair of the defect
with treatment of possible or manifest infection (peritonitis)
immediately following.
Generalized purulent peritonitis is treated conventionally.
Laparoscopic management of a complicated ulcer is possible if
certain conditions are met. Laparoscopic intervention requires a
surgeon experienced in the conventional treatment of the dis-
order and in laparoscopic surgical and suturing techniques.
The following surgical options are available:
1. Excision of the ulcer and closure of the remaining defect
with interrupted sutures through all tissue layers, if they are
pliable.
2. Definitive cure of “ulcer diasthesis.”
3. Postoperative Helicobacter pylorii treatment, if indicated.
Perforated duodenal ulcer: excision of the wall of the lesion and
vagotomy (selective proximal vagotomy, see p. 204).
Perforated prepyloric gastric ulcer or combined gastro-duodenal
ulcer: classic distal gastric resection by laparotomy.
An easily accessible perforation in the anterior cardia may be
managed laparoscopically. Excise the edge of the ulcer, close the
defect with interrupted sutures through all tissue layers, and
cover with an omental fold. In the case of easily accessible perforations in the anterior terminal esophagus, do not excise the
lesion. Cover the interrupted sutures (which pass through all
tissue layers) with a plication of the fundus.
Note: If any difficulties occur, conversion to an open procedure
is indicated.
Palliative measures are indicated in high-risk patients, taking
the respective individual clinical picture into consideration.
These include laparoscopy and sealing the perforation with a
balloon catheter and mesh collar to reduce the risk of infection,
and placing a nasogastric tube for gastric decompression.
Indications
− Free perforation, atypical perforation (“forme fruste”).
− Covered perforation with free air in the peritoneal cavity.
− Covered perforation without free air detected but suspicion
of peritonitis.
− In the presence of frank peritonitis, conventional laparotomy
is indicated.
Contraindications
− Anesthetic risks, see chapter 2.5.
− Perforation of the penetration through the posterior wall of
the stomach or duodenum, perforation or penetration into
the hepatoduodenal ligament.
− Perforation of the lateral and posterior cardia and
esophageal region.
− Generalized peritonitis.
− Perforation occurred over 12 hours before presentation for
treatment.
Surgical Risks and Patient Information
In 30% of all patients surgically treated for a perforated
gastroduodenal ulcer, the ulcer will recur without adequate
postoperative antibiotic and antacid treatment. New nonoperative treatment methods should reduce this incidence in
the future. Regular follow-up with endoscopic examinations is
recommended if symptoms recur.
Possible complications of free and covered perforated ulcers include localized or generalized peritonitis, and subphrenic or
subhepatic abscess. The risks for patients with perforated ulcers
depend on the patient’s age and the time elapsed before treatment, i. e., essentially on the severity of the infection or peritonitis and the extent of tissue necrosis. Mortality can be as high
as 10% or more. Perforation in combination with bleeding can
be life threatening (50% or higher mortality).
Preoperative diagnostic studies should look for signs of peritonitis and unexpected findings such as cancer. In the presence
of such findings, laparotomy is indicated. As in all laparoscopic
operations, intraoperative conversion to laparotomy does not
represent a complication.
Special Preparations
To confirm the diagnosis:
− Radiologic studies and endoscopy (with air insufflation if required).
− Gastric lavage and suction.
− Resuscitation (i. e., restore and maintain blood, protein, and
electrolyte balance).
− Antibiotic treatment.
− Urinary catheter.
− Nasogastric tube.
Anesthesia
General anesthesia.
170
Monitor
2
nd
assistant
Aspirator/
irrigator set
Isufflator
1
st
assistant
Electrocautery unit
Surgeon
Instrument table
OR nurse
Fig. 7.1.1 Closure of peptic ulcer perforation. Positioning. Position the
patient supine in a reverse Trendelenburg position with one arm extended
and the legs abducted and the patient slightly turned onto his or her left
side.
7.1 Closure of Peptic Ulcer Perforation
Positioning
(Fig. 7.1.1).
Position of the Operating Team
(Fig. 7.1.2).
The surgeon stands between the patient’s legs. The first assistant stands to the right of the patient, and the second assistant to the left. We recommend a reverse Trendelenburg
position with the patient turned moderately on his or her left
side.
The monitor with video recorder and light source is located at
the patient’s right shoulder. The respirator and the anesthesiologist are off to the left.
The aspirator/irrigator set is to the left and the electrocautery
unit, and insufflator are placed on the right side of the patient.
We recommend using a 30-degree laparoscope for better visualization of the surgical site.
Trocar Placement
Fig. 7.1.2 Perforated gastroduodenal ulcer.
Position of the operating team and equipment.
(Fig. 7.1.3).
Complications
171
Complications
Intraoperative Complications
Poorly accessible perforation site.
Corrective action: Convert to open procedure.
Extensive peritonitis, subphrenic and/or mesenteric abscess.
Corrective action: Convert to open procedure.
Injury to the spleen and esophagus require treatment by laparotomy. Non-bleeding tears in the capsule of the liver and
seromuscular defects of the stomach can be managed laparos-
copically as well as by laparotomy.
Immediate Postoperative Complications
Peritonitis.
Corrective action: Conventional laparotomy.
Bleeding from the gastroduodenal lesion:
a) Intraluminal bleeding.
Corrective action: Control bleeding endoscopically.
b) Bleeding into the peritoneal cavity.
Corrective action: Control persistent or recurrent bleeding by
conventional laparotomy.
Late Complications
Recurrent ulcer.
Corrective action: Perform diagnostic endoscopy with biopsy
and initiate appropriate nonoperative therapy. If this fails or
complications occur, surgical intervention is indicated.
Step-by-Step Procedure
1. Adjust the electrocautery unit to a medium setting.
2. Connect the aspirator/irrigator set.
3. Prepare a gastroscope.
4. Start the recording unit.
T3
T4
T2
T1
Fig. 7.1.3 Closure of peptic ulcer perforation. Trocar placement. First in-
sert the laparoscope/camera trocar about two finger breadths superior to
the umbilicus. Placement of the instrument trocars depends on the laparoscopic findings. To expose the left hepatic lobe, we recommend placing an instrument trocar at port T3 as shown. Place instrument trocars T2
and T4 as shown if a prepyloric perforation is detected. Place a large-
diameter nasogastric tube to protect the esophagus.
We recommend having a gastroscope ready to help locate the perfora-
tion. Open trocar placement is an alternative.
T1 Laparoscope/camera trocar (30-degree laparoscope)
T2 Grasper/probe
T3 Retractor/grasper with swab
T4 Grasper
II Establishing the pneumoperitoneum
1. Select pressure plateau according to patient’s size, age, and
weight (6−8 mm Hg for children; 10−14 mm Hg for adults).
2. Connect all equipment required for operation.
3. Make a skin incision about two finger breadths superior to the
umbilicus for the Veress needle and laparoscope/camera tro-
car.
4. Insert the Veress needle.
5. Perform safety tests: rotation, injection, aspiration, suction,
and manometer tests.
6. Perform insufflation procedure.
III Laparoscopy
1. Place nasogastric tube.
2. Insert laparoscope/camera trocar with tapered blunt-tip sty-
let and trumpet valve about two finger breadths superior to
the umbilicus directly through the linea alba.
3. Insert the instrument trocars under laparoscopic visualization.
4. Explore the peritoneal cavity with the 30-degree laparoscope.
5. Make diagnosis and determine plan of action.
6. Aspirate exudate for Gram stain, culture, and antibiotic sensitivity testing.
7. Excise the wall of the lesion (biopsy; see Fig. 7.1.5).
8. In the presence of an ulcer near the pylorus, continue with a
pyloroplasty (see Figs. 7.1.7 and 7.1.8).
9. Suture the defect.
Caution: Avoid stenosis of cardia or pylorus.
10. In the presence of a perforated chronic duodenal ulcer
without peritonitis, continue with selective proximal
vagotomy.
11. In the presence of a large perforation of a gastric ulcer, em-
ploy appropriate and individually indicated procedures for
treatment.
12. Place a drain at the surgical site (Surgeon’s choice).
13. Remove the instrument trocars under laparoscopic visualization.
Caution: Residual bleeding from the trocar incisions may
occur.
172
7.1 Closure of Peptic Ulcer Perforation
Bibliography
T3
T4
Fig. 7.1.4 Closure of peptic ulcer perforation. Exposing the perforation. If
a laparoscopic retractor is not available, you may use a swab (port T3) to
lift the left hepatic lobe. With a probe inserted through port T2, inspect
the anterior aspect of the stomach until the perforation is detected.
Boey J, Wong J, Wong G, Ong B. A prospective study of operatic risk factor in
perforated duodenal ulcer. Ann. Surg. 1982; 195:265.
Cuschieri A. Laparoscopic vagotomy. Surg. Clin. N. Am. 1992; 72:357.
v. Eiselsberg A. Zur Behandlung des Ulcus ventriculi et duodeni. Arch. klin.
Chir. 1920; 114:539.
Ferguson DJ, Billings H, Swensen D, Hoover G. Segmental gastrectomy with
innervated antrum for duodenal ulcer. Surgery 1960; 47:548.
Finsterer H. Ausgedehnte Magenresektion bei Ulcus duodeni statt der einfa-
chen Duodenalresektion bzw. Pylorusausschaltung. Zbl. Chir. 1918;
45:434.
Gunn AA, Siriwardema AK. Anterior lesser curve seromyotomy and posterior
truncal vagotomy for chronic duodenal ulcer: the results at five years. Brit.
J. Surg. 1988; 75:866.
Kahwaji F, Grange D. Ulcère duodénal chronique. Traitement par séromyo-
tomie fundique antérieur avec vagotomie tronculaire postérieur. Presse
Med. 1987; 16/1:28.
Katkhouda N, Mouïel J. Treatment of chronic duodenal ulcer with posterior
truncal vagotomy and anterior seromyotomy without laparotomy using
video coelioscopy. Ann. J. Surg. 1991; 161:361.
Largiadèr F. Segmentäre Magenresektion und Vagotomie beim Ulcus
duodeni. Schweiz. med. Wschr. 1971; 101:1204.
Mouïel J, Katkhouda N, Gugenheim J, Fabiani P, Goubaux B. Traitement de
l’ulcère duodénal par vagotomie tronculaire postérieure et séromyotomie
antérieur sous vidéolaparoscopie. Note préliminaire avec présentation de
film. Paris. Séance du 6 juin. Chirurgie 1990; 116:546.
Mouret P, François Y. Vignal J, Barth X et al. Laparoscopic treatment of per-
forated peptic ulcer. Brit. J. Surg. 1990; 77:1006.
Nathanson LK, Easter DW, Cuschieri A. Laparoscopic repair/peritoneal toilet
of perforated duodenal ulcer. Surg. Endosc. 1990; 4:232.
Schreiber HW. Perforation eines Ulcus duodeni sive ventriculi. In Kremer K,
Lierse W, Platzer W, Schreiber HW, Weller S. Chirurgische Opera-
tionslehre, Vol. 3, p. 234. Stuttgart: Thieme; 1987.
Taylor TV. Lesser curve superficial seromyotomy. An operation of chronic
duodenal ulcer. Brit. J. Surg. 1979; 66:733.
Taylor TV, Gunn AA, MacLeod DAD. Anterior lesser curve seromyotomy and
posterior truncal vagotomy in the treatment of chronic duodenal ulcer.
Lancet 1982; 320:846.
Taylor TV, Gunn AA, MacLeod DAD et al. Morbidity and mortality after ante-
rior lesser curve seromyotomy and posterior truncal vagotomy for
duodenal ulcer. Brit. J. Surg. 1985; 72:950.
Taylor TV et al. Anterior lesser curve seromyotomy and posterior truncal
vagotomy versus truncal vagotomy and pyloroplasty in the treatment of
chronic duodenal ulcer disease. Brit. J. Surg. 1990; 77:107.
Triboulet JP. Progrès dans le traitement de l’ulcère duodénal: la séromyo-
tomie avec vagotomie. In Mouïel J. Actualités digestive médicochirurgi-
th
cals, 10
ed, p. 15. Paris: Masson; 1989.
Fig. 7.1.5 Closure of peptic ulcer perforation. Obtaining a biopsy from
the perforation. After localizing the perforation and assessing its size and
nature, excise the wall of the lesion for histologic examination. If ex-
cisional biopsy is not possible, a biopsy must be done postoperatively by
gastroscopy after closure of the perforation has healed.
Complications
173
Fig. 7.1.6 Closure of peptic ulcer perforation. Suturing the perforation.
Close the defect after excision with interrupted sutures through all tissue
layers (Fig. 7.1.7). Cover the sutures with an omental fold where possible.
The suture line can be sealed with fibrin glue. Use absorbable sutures. See
chapter 2.3 for suturing technique (see Fig. 7.1.3 for key to instrument
numbers).
Fig. 7.1.8 Closure of prepyloric peptic ulcer perforation. Pyloroplasty.
Close the defect, including the incision across the pylorus, with interrupted sutures running perpendicular to the gastric passage. Cover the
sutures with an omental fold of healthy tissue where possible (see
Fig. 7.1.3 for key to instrument numbers).
a
Fig. 7.1.7a, b Closure of prepyloric peptic ulcer perforation. Prepyloric
location. Near the pylorus, excise the ulcer along the longitudinal axis of
the stomach and extend the incision caudally across the pylorus (a).
(b) The excision line (dashed line) is closed with interrupted sutures
through all tissue layers. Use absorbable sutures (solid line).
a
b
174
7.2 Laparoscopically-Assisted Gastric Resection
7.2 Laparoscopically-Assisted Gastric Resection
C. A. Schneider, M. F. Gioscia, L.U. Jung, F.M. Steichen
Objectives and Methods
Distal gastric resection, consisting of antrectomy or subtotal removal, has been performed for over a century (Theodor Billroth,
1881). The current indications for this procedure include both
benign and malignant disease. With the advancement of laparo-
scopic instruments and procedures, many operations once done
through large abdominal incisions can now be performed with
the assistance of the laparoscope, video image and appropriate
operative instruments. Complications of peptic ulcer disease
and symptoms refractory to nonoperative therapy are ideal circumstances for the laparoscopically-assisted gastric resection.
Malignant gastric disease may also be considered if diagnose d
early (the lesion limited to the gastric mucosa as determined by
intraluminal endoscopy and absence of lymph nodes on MRI or
CT, as well as by staging by laparoscopy at the time of planned
resection). The benefits of laparoscopy for resection of more significant gastric cancers has yet to be determined.
Indications
− Billroth I (antrectomy, gastroduodenostomy):
− Peptic ulcer disease refractory to nonoperative therapy,
− Gastric and prepyloric ulcers.
− Recurrent ulcers post vagotomy.
− Superficial gastric cancer as localized by transillumination during intraoperative transluminal gastroscopy.
− Billroth II (antrectomy, gastrojejunostomy):
− Dense scarring or inflammation around the duodenum.
− Refractory gastric or duodenal ulcers.
− Any condition that would make a Billroth I technically too
difficult or dangerous.
− Superficial gastric cancer as localized by transillumination during intraoperative transluminal gastroscopy.
Special Preparation
The patient should be aware that a small incision will be made
for delivery of the specimen and formation of the anastomosis.
He/she should always be informed that an open operation may
become necessary during the laparoscopic attempt. The standard preoperative work-up is used as it exists for open procedures.
Anesthesia
General endotracheal anesthesia.
Patient Position
The patient is placed in a supine position with the arms tucked
on the sides.
Position of Surgeon and Equipment
The surgeon stands on the right side of the patient and the assistant on the left. The monitors are placed cephalad to the
shoulders on either side. Alternatively, the surgeon may stand
between the spread legs of the patient.
Instruments:
− two endobabcock graspers,
− endosuture or laparoscopic needle driver,
− sutures (absorbable and non-absorbable),
− one 10-mm, two 12-mm, two 15-mm trocars,
− fan retractor,
− GIA 30 stapler, EEA and TA 90 stapler.
Contraindications
− Billroth I:
− Severe inflammation or scarring around the duodenum.
− Malignancy—full thickness of gastric wall or presence of
metastatic lymph nodes.
− Billroth II:
− Malignancy—full thickness of gastric wall or presence of
metastatic lymph nodes.
Operative Risks
The operative risks of laparoscopically-assisted gastric resection are the same as for the open procedure. These include
bleeding and pancreatitis for both types of anastomosis, and recurrent ulcer (0−4% long term). Dumping and GE reflux are
more common with the Billroth II anastomosis, (dumping occurring in 5−20% of cases). Most often this can be controlled by
dietary regulation. The mortality rate is 1−2% in uncomplicated
cases.
Port Placement
The camera port is placed at the umbilicus. Two ports are placed
lateral to the rectus muscle on either side approximately 2−
3 cm superior to the umbilicus. Two other ports are placed more
medially below the xiphoid and 6−8 cm apart. Care should be
taken to avoid placing these ports to close to the costal margin
as this may limit mobility. The left ports are 15 mm for insertion
of stapling devices. The right ports are 10−12 mm in size.
Complications
Intraoperative Complications
When performing any laparoscopic procedure, the risk of intraabdominal injury from trocar insertion is present. The trocar
can be inadvertently pushed into bowel, solid organs, or vascular structures, especially if the Veress needle is used for primary
insufflation. These risks can be greatly reduced if care is taken to
place the trocars under direct vision and with no excessive force
after the endoscope trocar has been placed by an open technique (Hassan). Bleeding and organ injury may occur during the
Postoperative Care
175
operation, therefore one must always be careful to expose structures well before tying or cutting, as in open procedures.
Another hazard is the inadvertent cautery burns to structures
other than the intended ones. Therefore, all instruments that
can create a delayed necrosis from cautery, have to be used with
care and expertise.
Since the development of the harmonic scalpel, an instrument
that uses ultrasonic vibrations to cauterize structures, electrical
injuries can be eliminated.
Postoperative Complications
The postoperative risks of laparoscopically-assisted gastric re-
section are the same as with the open procedure. These include
bleeding and pancreatitis for both types of anastomosis, and re-
Step-by-Step Procedure
1. The patient is placed on the operating table in the supine
position. The legs may be placed in abduction if preferred.
The monitors are at shoulder level so that the surgeon and
assistant are looking in the direction that they are operat-
ing.
2. A 2-cm transverse incision is made in the skin inferior to the
umbilicus, the fascia is incised vertically through the linea alba
and the peritoneum is opened. A blunt trocar (10 mm) is inserted and secured. Pneumoperitoneum to 15 mm Hg pressure is obtained.
3. Once the abdomen is insufflated, the endoscope or camera
are placed through the umbilical trocar, and the other trocars
are inserted under direct endoscopic vision at the lateral
borders of the recti, approximately 2−3 cm superior to the
umbilicus, and in the subxyphoid region approximately 8 cm
apart and just below the costal margins. The left trocars are
15 mm, the right are 12 mm (Fig. 7.2.1).
4. A Babcock is introduced through the left lateral trocar for
downward traction of the stomach. A fan retractor is introduced through the right superior port for retraction of the left
lobe of the liver (Fig. 7.2.2).
5. The right inferior trocar is used for the dissector/scissors to incise the peritoneum and expose the vagi (Fig. 7.2.2).
6. The vagi are doubly clipped and a portion is excised for patho-
logic examination (Figs. 7.2.2 and 7.2.3).
7. Stay sutures are placed along the greater and lesser curvatures for traction on the stomach during dissection. Pull the
lesser curvature suture out through the right lateral trocar,
the greater curvature suture through the left lateral trocar
(Fig. 7.2.3).
8. Using a Babcock to retract the stomach anteriorly, the gastrocolic ligament is divided to enter the lesser sac and begin mo-
bilization of the stomach (Fig. 7.2.4).
9. The dissection is continued beyond the pylorus and the ulcer.
10. A small midline upper abdominal incision 4−5 cm in length is
made (a longer incision can be made to facilitate the pro-
cedure in obese patients). The incision should be low enough
below the xypoid so that the duodenum and the pylorus can
be visualized (Fig. 7.2.5) and exposed directly, deep to the in-
cision.
11. The stomach and pylorus are brought into the incision and
the lesser curvature is dissected. Clips or ties may be used to
ligated the vessels here. The stay sutures that were pulled
through the lateral trocars are now brought out through the
midline incision (Fig. 7.2.6).
current ulcer (0−4% long term). Dumping and GE reflux are more
common with the Billroth II anastomosis, (dumping occurring in
5−20% of cases). Most often this can be controlled by dietary regulation. The mortality rate is 1−2% in uncomplicated cases.
Postoperative Care
After gastric resection, the patient should be given one to two
doses of prophylactic antibiotics. The nasogastric tube remains
in place for 24−36 hours on low suction. We like to use low dose
heparin and sequential compression boots for DVT prophylaxis,
but also encourage early ambulation. Once the patient has flatus, a clear liquid diet is prescribed, and advanced to a standard
post-gastrectomy diet as tolerated.
Gastroduodenostomy
12. Make a transverse incision in the duodenum distal to the pylorus/ulcer (Fig. 7.2.7).
13. Insert the anvil of the EEA with its “leash” attached through
the duodenal incision. Leave the leash exposed in the incision
(Fig. 7.2.7).
14. Place a clamp (straight Kocher) across the duodenum proximal to the incision. Staple the duodenum distal to the incision
using the TA30 (or TA60 if needed) (Figs. 7.2.8a, b).
15. Using the scissors or sharp knife, transect the duodenum be-
tween the staple line and the Kocher clamp. Be sure to avoid
cutting the leash at this point (Fig. 7.2.9a).
16. Pull the anvil leash until the anvil advances through the staple
line (Fig. 7.2.9a).
17. Remove the anvil leash (Fig. 7.2.9a).
18. Make a transverse anterior gastrotomy distal to the planned
line of resection (Fig. 7.2.9a).
19. Insert the cartridge of the EEA into the gastrotomy
(Fig. 7.2.9a).
20. Pass the trocar of the cartridge through the posterior wall of
the stomach proximal to the stay sutures. (Fig. 7.2.9b).
21. Retract the stomach anteriorly and to the left for visualization
of the posterior stomach wall (Fig. 7.2.9c).
22. Mate the two portions of the EEA and fire the stapler
(Fig. 7.2.9c).
23. Remove the EEA mechanism (Fig. 7.2.9d).
24. Place a TA 90 across the distal stomach at the planned line of
resection (Fig. 7.2.9d).
25. Once the staples have been fired, he distal stomach can be
transected and removed (Fig. 7.2.10).
Gastrojejunostomy
26. Once the duodenum has been transected, the distal stomach
is retracted anteriorly into the midline incision. A loop of je-
junum just distal to the ligament of Treitz is brought to the
posterior surface of the stomach cephalad to the planned line
of resection (Fig. 7.2.13).
27. Make a gastrotomy and enterotomy and insert the two por-
tions of the GIA stapler (Fig. 7.2.13), mate and fire the GIA sta-
pler.
28. Place gentle traction on both limbs of the jejunum. Align a
TA 90 along the line of resection, including the GIA introduction site (Fig. 7.2.14).
29. When the TA 90 is fired and the anastomosis is complete, the
distal stomach can be transected and removed from the field
(Fig. 7.2.14).
176
7.2 Laparoscopically-Assisted Gastric Resection
Operative Procedure
Fig. 7.2.1 After insertion of the umbilical trocar, the abdomen is insuf-
flated and the 0° scope is inserted. Four other trocars are then placed. The
two lateral ports are placed lateral to the rectus muscles. The middle
ports are placed on either side of the xiphoid, cephalad to the lateral
ports. The left ports are 15 mm to allow for stapling devices.
Fig. 7.2.2 Before gastric resection, an anterior and posterior truncal
vagotomy is performed. The left lobe of the liver is retracted anteriorly
and to the right. A Babcock is used to retract the stomach inferiorly, grasping its anterior surface in order to avoid unnecessary bleeding.
The peritoneum overlying the esophagus is incised to expose the anterior
vagus, which is then dissected and ligated with endoclips. The esophagus
is then retracted to the left to expose the posterior vagus for ligation in
the same fashion. Segments of both vagi are sent for histological confirmation. The anterior surface is cleared of all small vagal branches.
Fig. 7.2.3 The lesser sac is then entered through the gastrocolic ligament. The gastroepiploic vessels are ligated using endoclips or the en-
dovascular GIA. The left gastric artery may be identified posterior to the
elevated stomach and ligated at this point, or may be addressed when the
antrum is brought through a small midline incision.
The mobilization of the stomach is continued beyond the pylorus and the
duodenal ulcer.
Fig. 7.2.4 Stay sutures are placed along the lesser curvature (the angle
of incisura) and the greater curvature and should delineate the future line
of resection. These sutures are pulled through the lateral trocars.
Gastroduodenostomy Anastomosis
Operative Procedure
177
Fig. 7.2.5 Now a small (4−5 cm) midline incision is made in the upper ab-
domen exposing the antrum and pylorus. This should be large enough to
bring the stomach into the wound.
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Fig. 7.2.6 The dissection of the lesser curvature is then completed to
free this portion of the stomach, including the left gastric artery if necessary, if this step had not been accomplished before this stage of the
operation.
Fig. 7.2.7 After thorough mobilization of the antrum and pylorus, a
transverse incision is made in the anterior surface of the duodenum distal
to the ulcer and/or the pylorus. The anvil portion of the EEA is inserted
into the duodenum. A suture or “leash” is secured to the tip of the anvil,
to facilitate its retrieval later.